Irritable newborn presents with worsening pustular rash
What’s your diagnosis?
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A 5-day-old female is transferred from another hospital due to irritability and a worsening pustular rash. The mother’s pregnancy, labor and delivery was complicated by a group B strep-positive culture and vaginal candidiasis.
Per protocol, the mother was given ampicillin during labor, and the baby’s Apgar scores were 8 and 8. By the end of the baby’s third day of life, she began developing pustular lesions, in no particular pattern, accompanied by mild irritability. She then underwent a sepsis workup, including CSF, urine and culture of a pustule, and treatment with acyclovir, ampicillin and gentamicin were empirically started. The lab results were normal, including negative cultures, CSF Gram stain and herpes PCR. With ongoing worsening of the rash, she was continued on her current therapy and transferred to your NICU.
Examination on arrival is that of a healthy-appearing neonate with a diffuse, pustular rash (Figure 1).
Her vital signs are normal, with no oxygen requirement or distress. Lab tests on admission showed a CBC with 19,000 WBCs and a slight predominance of segmented neutrophils. Pustular material is sent for Gram stain and repeat culture. The Gram stain is shown in Figure 2.
What’s your diagnosis?
A. Erythema toxicum
B. Neonatal cutaneous candidiasis
C. Neonatal cutaneous herpes simplex
D. Neonatal staph pustulosis
Answer and discussion:
The answer is B, neonatal cutaneous candidiasis, a superficial fungal infection of the skin of newborns. The organism is typically acquired during birth from a mother with Candida albicans in the birth canal. The lesions can appear as early as the first day of life and may continue to appear if not treated. They are typically in a general distribution, and if a pustule is stained, budding yeast and pseudohyphae can be seen, as shown in Figure 2. The fungal culture will typically be positive. True congenital candidiasis (acquired in utero) is a potentially life-threatening, disseminated infection with positive blood, urine and/or CSF cultures, and it can present cutaneously. There may be those with elements of both who are not significantly ill. Others may use the term congenital neonatal candidiasis, which I find confusing. Whatever you call it, treatment should be chosen based on the clinical presentation, and amphotericin B can be used if there is concern about true systemic disease, or one can use oral fluconazole for limited, more focal disease, such as in the patient presented in this case. Those with just a small number of lesions may even be treated with topical agents. The patient in this scenario was treated with oral fluconazole, with complete clearing of the cutaneous lesions within 10 days (Figure 3).
Erythema toxicum (Figure 4) is a common, benign neonatal skin condition, consisting of small pustules on erythematous bases that are usually seen in the first few days of life. If material is removed and sent for hematoxylin and eosin staining, one should see eosinophils. However, in most cases, the diagnosis can be made on appearance alone. No treatment is necessary.
Neonatal herpes simplex virus infection is a serious, life-threatening infection in young infants. Lesions may look similar to those shown in this vignette. The main differences include the time of onset: day 3 with neonatal cutaneous candidiasis vs. 5 to 10 days with neonatal HSV. Of course, there are exceptions to this day-of-onset “rule,” and it should not be used as a reason to dismiss the possibility of HSV. Also, the lesions had minimal erythema about the base, as one expects with herpes (Figure 5). Also, in this case, the Gram stain of a pustule contained budding yeast and pseudohyphae.
Staphylococcal pustulosis is rarely seen anymore with modern newborn cleaning and management. It may represent as a simple pyoderma or a manifestation of widespread infection and sepsis. The lesions may be simple pustules or bullous lesions if the strain of the causative staph is an epidermolytic toxin-producing strain, or a mix of both (Figure 6).
In November 2000 (23 years ago), I presented this case. Since then, not much has changed. One major advance is that now there are rapid diagnostics to detect HSV and C. albicans DNA by PCR in blood for those suspected of disseminated disease.
Columnist comments:
Have you ever heard of a rare complication of giving vaccine injections called SIRVA? Neither have I, until some time ago when I had a fairly severe, tetanus-prone injury and fit criteria for a tetanus booster. While I was having an IV started and an open wound closed, someone came into the room to give me a tetanus shot. I immediately noted that it was unusually painful and higher than usual on my arm. Later, when I looked in a mirror, I noted the Band-aid was right over the joint, just under the acromion. The pain was fairly remarkable and lasted about 6 months, then gradually faded but never really resolved. Several years ago, a doctor friend questioned me about the risks of having just received an influenza vaccine injection into her shoulder joint. Also, like many of you during the COVID-19 pandemic, I watched many news reports that included stock videos of people receiving shots in their arms. On several of these occasions, I saw what appeared to be injections given very high on the arm, essentially at the joint, and it occurred to me that this may not be all that rare after all.
SIRVA is an acronym for “shoulder injury related to vaccine administration.” It turns out that there are numerous case reports on this vaccine complication. It has been described as a rare complication of vaccine administration; however, it is likely more common than currently thought because most patients (like me and my colleague) probably never report it, assuming it is just a shot that happens to have longer lasting pain. There have been a few case reports that describe the consequences, which include bursitis, tendonitis, adhesive capsulitis, etc. Of those seeking medical care for this complication, the average age is about 50 years, and about 75% are females. A good review can be found here.
The point of this is to advise you to protect yourself by placing your hand over the acromion of your shoulder, forcing the one who is administering the shot to choose a more appropriate location further down your arm. Also, review proper injection sites and techniques with those under your influence.
All that being said, be sure to take your flu shot next month, and be on the lookout for the new RSV (respiratory syncytial virus) vaccines and the next COVID-19 vaccine dose. Good Luck, and please keep in touch.
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Brien is a member of the Healio Pediatrics Peer Perspective Board and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.